ANESTHESIA for Dental MAXILLOFACIAL SURGERY

1. ANESTHESIA for Dental& MAXILLOFACIAL SURGERY SAAD A. SHETA MBChB, MA, MD Associate Professor, Anesthesia Dental College KSU

2. Dental Anesthesia I. Out-Patient anesthesia II. Day-Case anesthesia III. In-Patient anesthesia V. Emergency Surgery

3. Out-Patient Dental Anesthesia Dental Chair Anesthesia

4. Out-Patient Dental Anesthesia Dental Chair Anesthesia Out-Patient dental extraction Children (4-10 years): URTI Steadily decreased

5. Out-Patient Dental AnesthesiaInduction Inhalational (mask) induction Intravenous Induction

6. Out-Patient Dental AnesthesiaMaintenance Inhalational agents/N2O Maintain airway Posture (Supine Position) Less hypotension less bradycardia However high risk of aspiration high risk of Airway obstruction

7. Out-Patient Dental AnesthesiaRecovery Left lateral position 100% O2 Suction Observation & monitoring Discharge criteria Instructions Analgesia (NSAIDs)

8. Out-Patient Dental AnesthesiaComplications Respiratory Complications Cardiovascular Complications Syncope Allergic Reaction

9. Respiratory Complications Airway Obstruction Respiratory Depression

10. Cardiovascular Complications Hypotension Bradycardia Dysrhythmias (Tachy-arrhythmias) Aetiology (Tooth extraction) High preoperative catecholamines Light anesthesia Airway obstruction & hypoxia Halothane & local anesthesia Local anesthesia with vasopressors

11. Syncope Causes Previous factors (CV, allergic,..) Emotional factors (more common) Aetiology limbic cortex-hypothalamus-reflex vasodilatation Increase parasympathetic activity-bradycardia Management Head down-leg elevated 100% O2 Cessation of anesthesia

12. Allergic Reaction Incidence Very rare More commonly (vaso-vagal, toxic reaction, epinephrine) Aetiology Ig E-mediated reaction Easter-linked: p-amino benzoic acid Amide-linked: preservatives (Paraben) Manifestations Management

13. Day-Case Dental Anesthesia Minor Oral Surgery& Conservative Dentistry

14. Day-Case Dental AnesthesiaConcerns Rapid Recovery Minimal Postoperative Morbidity Remote Location

15. Day-Case Dental Anesthesia  Minor oral surgery and conservative dentistry Limited surgery No significant risk of complications Standard criteria of patient selection (ASAI&II)

16. Day-Case Dental AnesthesiaAnesthetic Technique Induction Inhalational (pediatrics) or Intravenous (propofol) Airway Nasal Endotracheal tube Oral intubation LMA Nasal mask& Nasophryngeal airway Intubation NDMR (short acting) Suxamethonium (Postoperative Mylegia) Deep Inhalational Anesthesia Propofol & Alfentanil Moist Pharyngeal Pack

17. Day-Case Dental AnesthesiaAnesthetic Technique Maintenance Inhalational Sevoflurane Isoflurane Halothane (slow recovery & cardiac arrhythmias) Ventilation Spontaneous (Short procedure) Controlled ventilation Extubation Throat pack removed Very light anesthesia (recommended) Patient turned to one side

18. Day-Case Dental AnesthesiaAnesthetic Technique Recovery& PO Minimum 2 hrs Pain Control NSAIDs (IM diclofenac) Short acting opioids Local analgesic block (2Quadrants only ) Preoperative Dexamethazone Discharge Assessment (Morbidity) Written instructions Contact telephone number Possible overnight admission

19. In-Patient Dental Anesthesia Major Oral & Fasciomaxillary Surgery

20. In-Patient Dental Anesthesia Classifications:  Major Orthognathic Surgery Tumor Surgery Palate Surgery

21. In-Patient Dental AnesthesiaConcerns: 

22. Airway Management Anesthetic Management

24. Airway Management Choice of the technique depends on several factors: Patient safety Experience of the anesthetist Known difficult airway Requirement: nasal or oral Post operative jaw wiring

25. Airway Management History Physical Examination Further Evaluation Difficult Airway & Algorism Airway Strategies

26. History Documented History of Difficulties with general anesthesia or, more specifically, mask ventilation or endotracheal intubation Congenital Syndromes Associated With Difficult Endotracheal Intubation Pathologic States That Influence Airway Management

31. Physical Examination Inspection (Obvious Problems) Mouth Opening (3 � 4cm) Oral Cavity Examination Mallampati Score Thyromental Distance (3 large fingers = 5 cm) Neck Movement

33. Further Evaluation PRE-OPERATIVE ASSESSMENT OF THE AIRWAY Indirect or Fiberoptic Laryngoscopy X ray: Chest , Cervical Spine CT or MRI Flow- Volume Loops Pulmonary Function Tests

35. Difficult Airway Difficult airway The clinical situation in which a conventionally trained anesthesiologist experiences difficulty with mask ventilation, difficulty with tracheal intubation, or both Difficult mask ventilation 1) inability of unassisted anesthesiologist to maintain SpO2 > 90% using 100% oxygen and positive pressure mask ventilation in a patient whose SpO2 was 90% before anesthetic intervention; Or 2) inability of the unassisted anesthesiologist to prevent or reverse signs of inadequate ventilation during positive pressure mask ventilation

36. Difficult Airway Difficult Laryngoscopy Not being able to see any part of the vocal cords with conventional laryngoscopy Difficult Intubation Proper insertion with conventional laryngoscopy requires either : a) > 3 attempts b) > 10min

41. AWAKE TECHNIQUES Glosso-Pharyngeal Nerve IX Nerve Posterior pharyngeal fold at its midpoint, 1 cm deep to the mucosa of the lateral pharyngeal wall

42. AWAKE TECHNIQUES Superior Laryngeal Nerve Pyriform Fossa External :1 cm medial to the superior cornu of the Hyoid Bone to pierce the thyrohyoid membrane

43. AWAKE TECHNIQUES Trachea & Vocal Cord Atomizer Injection

44. Laryngoscope Blades

47. AWAKE TECHNIQUES FIBER OPTIC INTUBATION

50. Laryngoscope Blades

52. GA TECHNIQUES Laryngeal Mask Airway (LMA)

53. GA TECHNIQUES LIGHTED STYLETS/LIGHTWAND

56. GA TECHNIQUES FIBER OPTIC INTUBATION

58. GA TECHNIQUES BULLARD LARYNGOSCOPE

60. Classification According to Mouth Opening

65. NEVER PARALYSE UNTILL POSSIBLE VENTILATION HAS BEEN ESTABLISHED RECENT SUCCESSFUL INTUBATION DOESNOT MEAN FUTURE POSSIBLE INTUBATION FULL RANGE OF DIFICULT INTUBATION EQUIPMENT MUST BE AVAILABLE

66. ALL PHYSICIANS RESPONSIBLE FOR AIRWAY MANAGEMENT SHOULD BE PRACTICED IN AT LEAST ONE ALTERNATE TO BAG & MASK VENTILATION. THESE ALTERNATIVE INCLUDES THE FOLLOWING: LARYNGEAL MASK AIRWAY COMBI TUBE TRANSTRACHEAL TECHNIQUES LMA PROVIDE RESCUE VENTILATION IN 94% OF CASES OF UNANTICIPATED DIFFICULT INTUBATION

67. HAVING DISCUSSED ALL THE MANAGEMENT STRATEGIES AWAKE TECHNIQUE IN GENERAL & AWAKE FIBER OPTIC TECHNIQUE ESPECIALLY, IS THE MOST COMMONLY USED & SAFE TECHNIQUE

69. Special Consideration Preoperative Management Intraoperative Management Post operative Management

70. PRE-OPERATIVE PROBLEMS Elderly, Chronically Debilitated Patients Malnourished H/O Heavy Smoking with Resultant COPD H/O Alcoholism Co-existing disease such as HTN,D.M, IHD, etc.

71. PRE-OPERATIVE MANAGEMENT Adequate pre-operative work-up of Cardiac Status & Pulmonary Functions should be carried out using various diagnostic modalities with the objective of optimizing patient�s condition

72. RECONSTRUCTIVE MAXILLOFACIAL SURGERY Problems: Major problem: Airway Management Extensive, long operation Significant blood loss Poor nutritional status Micro-vascular surgery Caution with Vasoconstrictors Caution with Transfusion Caution with Diurresis Blood Rheology (Hct:25-27)

73. INTRA-OPERATIVE Routine Monitoring NIBP ECG SPO2 ETCO2 TEMPERATURE Choice of Volatile Agent Choice of Anesthesia

74. INTRA-OPERATIVE MANAGEMENT

75. INTRA-OPERATIVE MANAGEMENT Two Large Bore Canulae After induction of anesthesia, two large bore canulae can be put in large veins so that rapid fluid replacement can be carried out in case need arises.

76. INTRA-OPERATIVE MANAGEMENT Invasive Blood Pressure Monitoring is indicated due to following reasons : Blood loss may be rapid secondary to Neck dissection Pre operative radiotherapy Surgery close to big vessels of neck Frequent fluctuations in the blood pressure due to manipulation in the area of carotid body and sinus.

77. INTRA-OPERATIVE MANAGEMENT Central Venous Pressure Monitoring Risk of venous air embolism during neck dissection As a guide to the management of fluid therapy The site of insertion is either: Antecubital vein Femoral vein

78. INTRAOPERATIVE MANAGEMENT Use of Muscle Relaxants During surgery IPPV is carried out without muscle relaxant as surgeons need to identify the nerves during surgery

79. INTRAOPERATIVE MANAGEMENT Induced Hypotension Mild degree of hypotension is required during surgery to reduce the blood loss. This can be achieved by following: 15-30 degree head up tilt Increasing the conc. of volatile anesthetics Use of peripheral vasodilators Use of beta blockers

80. INTRAOPERATIVE MANAGEMENT Blood Transfusion Before the decision of blood transfusion the following points should be considered Patient�s underlying medical condition Possibility of risks of transfusion hazards Increased risk of post-transfusion cancer recurrence as a result of immune suppression

81. INTRAOPERATIVE MANAGEMENT Haemodynamic Changes During radical neck dissection, the traction or pressure on the carotid sinus and / or stellate ganglion can cause following:- Brady-dysrhythmias Sinus arrest leading to asystole Wide swings in blood pressure Prolonged QT Interval

82. INTRAOPERATIVE MANAGEMENT Haemodynamic Changes �Treatment� Immediate cessation of the stimulus Blockage of the sinus with local anesthetic by the surgeon Vagolysis by atropine

83. INTRAOPERATIVE MANAGEMENT Venous Air Embolism When the venous pressure in neck veins is low and these veins are open to atmosphere, air is sucked in causing air embolism. Diagnosis Early Detection Hypoxia Hypotension Hypocarbia

84.  Venous Air Embolism Treatment Compression of neck veins Positive pressure ventilation Place the patient in the left lateral position Aspiration of air through the central venous catheter Ionotropes

85. POST-OPERATIVE CARE ROUTINE CARE SPECIAL CONSIDRATIONS ICU care & Possible mechanical Ventilation Hemodynamic Instability Analgesia Tracheostomy

86. POST-OPERATIVE CARE ICU Care & Possible Mechanical Ventilation Patient should be kept in the intensive care unit for 24-48 hours Prolonged Surgery Airway Oedema Co-existing diseases Risk of bleeding and/or neck hematoma

87. POST-OPERATIVE CARE Haemodynamic Instability As bilateral neck dissection may result in post-operative hypertension and hypoxic drive because of the denervation of the carotid sinus and carotid body

88. POST-OPERATIVE CARE Analgesia Non Steroidal Anti-inflammatory Agents should be used as opioids cause respiratory depression in spontaneously breathing patients When patient is on ventilator opioid analgesia can be given

89. POST-OPERATIVE CARE Tracheostomy Care Humidified Oxygen Intermittent Suction Sterile Precautions Adjustment of cuff pressure to15-20 mmHg Complications

90. THANK YOU